Cross-sectional study on public health knowledge among first-year university students in Japan: Implications for educators and educational institutions

In recent years, there have been increasing knowledge gaps and biases in public health information. This has become especially evident during the COVID-19 pandemic and has contributed to the spread of misinformation. With constant exposure to disinformation and misinformation through television, the internet, and social media, even university students studying healthcare-related subjects lack accurate public health knowledge. This study aimed to assess university students’ knowledge levels of basic public health topics before they started their specialized education. Participants in this cross-sectional study were first-year students from medical schools, health-related colleges, and liberal arts colleges. A self-administered electronic survey was conducted from April to May 2021 at a private university in Japan, comprising six colleges with seven programs. Data analysis, conducted from June to December 2022, included students’ self-reported public health knowledge, sources of information, and self-assessment of knowledge levels. Among the 1,562 students who received the questionnaire, 549 (192 male [35%], 353 female [64.3%], and 4 undisclosed [0.7%]) responded to one question (participants’ response rate for each question; 59.6%–100%). The results showed that students had limited public health knowledge, especially in sexual health topics, and 10% of students reported not learning in class before university admission the following 11 topics: two on Alcohol, Tobacco, and Other Drugs; eight on Growth, Development, and Sexual Health; and one on Personal and Community Health. These results indicate significant knowledge gaps and biases, as well as gender gaps, in public health education, especially in the area of sexual health, which may help educators and educational institutions to better understand and prepare for further specialized education. The findings also suggest a need to supplement and reinforce the foundation of public health knowledge for healthcare majors at the time of university admission.

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• foundation of public health knowledge in healthcare majors at the time of university admission.

Introduction
Public health knowledge is essential to a healthy society.
In recent years, the incidence of sexually transmitted diseases (STDs) has increased in industrialized countries [1][2][3][4][5], including Japan [6,7], with a significant rise during the COVID-19 pandemic.The increase in STDs among females in their 20s and 30s, especially the prevalence of Chlamydia infections among females in their teens, is particularly notable in Japan [8,9].STD prevention is an integral part of public health, and it is taught in health and physical education in Japan.Historically, sexual education as an essential ingredient of health and physical education changed from "non-existent" to "teaching chastity" in 1949, after which sex-segregated sexual education was mainly concerned with physiological differences or merely teaching about menstruation, which further evolved to somewhat sexintegrated education in Japan only in recent years [10,11].In spite of the fact that topics such as gender equality, social justice, reproductive rights, and public health education have begun to be addressed, female students still prefer single-sex sexual education and female educators.
In the presence of other sexes in the same room, sexual health can be uncomfortable to discuss or study [12], which makes conversations among them more challenging.
According to previous studies, there is a notable difference between the genders in their preferred sources of knowledge regarding sexual health.Female students' ideal source of information was reported to be school as the primary source, followed by parents, friends, and the Internet.In contrast, male students preferred school as the primary source, followed by the Internet, friends, and parents, suggesting that there might be a difference in sexual education needs at home between male and female students [13].Although diverse information sources generally mean more accurate knowledge of sexual health [14], not all information sources provide accurate information [15,16], especially information sources such as the internet.Internet-based information could potentially be harmful due to the presence of inaccurate, misleading, or incomplete information based on insufficient or unsubstantiated "scientific" evidence or even sensational, anecdotal views [16].In fact, people with lower health literacy were more likely to use and trust health information from social media, blogs, or celebrity webpages [17].
Education regarding STD prevention and basic public health education is included in the standard curriculum guidelines issued by the Ministry of Education, Culture, Sports, Science, and Technology (MEXT) under Health and Physical Education in Japan [18,19].However, health and sexual health education are not necessarily required for enrollment in any college because health topics are not included in entrance exams, leaving the extent of public health topics to each educator's discretion prior to university enrollment.This possible lack of public health education also applies to students enrolled in healthcare-related universities.
Healthcare professionals are required to disseminate this information.The lack of or inaccurate public health knowledge among healthcare professionals has a direct effect on the public.However, obtaining accurate health information is not necessarily equally easy for people of different social and economic backgrounds or even sexes.It has been reported that there are digital disparities, in which, higher socio-economic status and higher education are factors positively associated with digital health information seeking, which could result from either a disparity of access, or a disparity of literacy and comprehension [15,16,20].There have also been gender gaps in education [21,22].In addition, there are other factors affecting public health knowledge, including promoting abstinence-only education, the lack of sexual health education altogether, or even the discouraging of its provision [23,24] .With constant exposure to disinformation and misinformation through television, the Internet, and social media [15,25], it is imperative that younger generations, especially future healthcare providers, are given accurate health information that is the best available at the time.
Since the establishment of Health promotion in the 1986 Ottawa Charter by the World Health Organization in Ottawa, Canada [26], numerous studies, reports, and surveys have been conducted on sexual education worldwide.However, it is unknown whether future healthcare professionals will acquire adequate health and public health knowledge before enrolling in university.
In this study, we surveyed healthcare-related college students to assess their level of public health knowledge and evaluate whether they have adequate knowledge before proceeding to specialized education in healthcare-related universities.The findings of this study can be beneficial for educators to supplement the gap in students' essential knowledge, especially healthcare-related college students, in the aftermath of the COVID-19 pandemic.

Method Study design and participants
We developed a self-administered questionnaire designed to assess and evaluate first-year university students' knowledge of public health topics and conducted a cross-sectional study at Juntendo University, Tokyo, Japan.In order to assess public health knowledge prior to university with minimal influence of health-related knowledge from university classes, we selected first-year students within two months of admission to Juntendo University.Juntendo University is a private university that focuses on health science, comprising six colleges with seven programs: medicine, health care and nursing, health science and nursing, health science/radiological technology, health science/physical therapy, health and sports science, and international liberal arts.Table 1 presents the program characteristics.

Questionnaire and survey
To examine differences in students' awareness and knowledge of health and public health, we identified essential topics and health knowledge from the Japanese curriculum guidelines, educational policies, educational contents of textbooks, and standard health education policies stipulated by the Centers for Disease Control and Prevention (CDC).We selected several crucial health education sections and topics shared by Japan and the United States: 1) Nutrition and Physical Activity; 2) Growth, Development, and Sexual Health; 3) Injury Prevention; 4) Alcohol, Tobacco, and Other Drugs; 5) Mental and Social Health; and 6) Personal and Community Health.We identified 31 knowledge topics for the educational content, which are listed in Supplemental Table S1.For each of these knowledge topics, we developed a set of three self-assessment questions, including: 1) the presence/absence of knowledge (acquired in class); 2) information sources for the knowledge; and 3) the level of knowledge on a 10-point scale ranging from 1 (no knowledge at all) to 10 (enough knowledge to teach someone else).In total, we prepared 86 self-assessment questions.We prepared five questions on knowledge of lifestyle-related diseases, contraception, LGBTQIA+ issues, pathogens causing infections, and transmission of infection, for a total of 91 questions (Supplemental Table S2).We developed the survey questions in consultation with medical and health education experts.We prepared a survey using Google Forms and administered it to all freshmen in all departments.All survey data was collected anonymously.The questionnaires included self-reported sex (i.e., male, female, undisclosed, or other).With a racially homogeneous environment and most university enrollment occurring immediately after high school, we did not ask about ethnicity or age to maintain anonymity.We consulted with two native English bilinguals and two native Japanese bilinguals to translate the questions and answers.

Data analysis
Descriptive analyses were performed to examine the respondents' characteristics and responses.Frequencies and percentages were utilized for categorical variables, and means and standard deviations, or medians and 95% confidence intervals were utilized for continuous variables.If there was at least one answer to a question, the answer was accepted.
Unless otherwise stated, the percentage was calculated based on the number of responses to each question.The number of topics for which students reported having knowledge and selfassessment knowledge levels was calculated as a percentage of the total knowledge score and total knowledge self-assessment score, and normality was tested using the Shapiro-Wilk test.
We evaluated the total knowledge and self-assessment scores using Kruskal-Wallis tests and one-way analysis of variance, respectively, to evaluate whether there was a difference between colleges.The undisclosed sex group was excluded from the examination based on sex comparison.The Pearson's chi-square test was used to examine sex-based differences.Ztests were used to further explore the differences, and the Bonferroni correction was employed to adjust for multiple comparisons.Mann-Whitney U tests were used to examine the mean rank differences in self-assessment by sex.
All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (Armonk, NY: IBM Corp.).The p-value threshold for significance was adjusted for multiple comparisons using the Bonferroni correction.The threshold for statistical significance was set at p < .05.

Ethics statement
This study was approved by the Juntendo University Ethical Review Board (No.

2020324) and followed the Strengthening the Reporting of Observational Studies in
Epidemiology Reporting Guidelines.We obtained informed consent from respondents and collected the completed questionnaires.3B).

Self-assessment of knowledge level
The lowest level of self-assessed knowledge was 4.0 (95% CI, 4.0-5.0)for topics such as the health effects of e-cigarettes, women's basal body temperature, and LGBTQIA+ issues.Meanwhile, the highest level of self-assessed knowledge was 7.0 (95% CI, 7.0-8.0) for topics such as the health effects of smoking, the health hazards of passive smoking, smoking dependence, the mental and physical effects of mind-altering drugs, and ovulation and menstruation.

Comparison of previous knowledge and class involvement by sex
There was a significant difference between males and females in their previous knowledge of topics such as allergic reactions, alcohol consumption effects on pregnancy, ovulation and menstruation, ejaculation, how to use condoms, women's basal body temperature, measurement of women's basal body temperature, public services related to pregnancy, abortion under the Maternal Health Act in Japan, and sex and gender (Table 3A).
Moreover, there were significant differences between males and females in reporting that they did not learn about certain topics in their classes, such as lifestyle-related disease, allergic reactions, ovulation and menstruation, how to use condoms, women's basal body temperature, measurement of women's basal body temperature, abortion under the Maternal Health Act in Japan, and sex and gender (Table 3B).

Comparison of sources of information by sex
Significantly more male students selected their teacher(s) as sources of information about LGBTQA+.However, significantly more female students selected their parent(s) as the source of information on the six topics.Furthermore, significantly more male students selected their friend(s) as a source of information than female students did for 20 out of the 271 29 topics.Additionally, significantly more male students reported the Internet as a source of 272 information than female students for 16 out of 29 topics, while more female students reported 273 the Internet as a source on one topic (Table 4).274

Comparison of self-assessment by sex 275
The results of the Mann-Whitney U test demonstrated that male students reported 276 significantly higher self-assessment scores on seven out of 29 topics, while female students 277 reported significantly higher scores on five out of 29 topics (Table 5).278

283
This study aimed to assess the knowledge, sources of information, and self-284 assessment of essential public health topics among university students before beginning their 285 healthcare education, as well as to evaluate differences in the choice of colleges that indicate 286 their desired career path.To the best of our knowledge, there has been no prior investigation 287 into the public health knowledge of healthcare university students before beginning their college education.
Although students reported being familiar of most of the health topics surveyed, there appeared to be a lack of knowledge in certain areas and reliance on skewed information sources, as detailed below.

Nutrition and Physical Activity
Ninety percent or more of the students affirmed their awareness of all three questions related to food poisoning and allergies, and reported their parent(s) and the Internet as sources of information.This finding suggests that education on health knowledge related to daily life is likely to be provided at home.Although many students reported the internet as their source of information, it is important to note that the information available on the internet is not necessarily accurate.This could be particularly critical in situations related to food poisoning or allergies, where inaccurate information could have serious consequences.

Alcohol, Tobacco, and Other Drugs
Numerous students reported obtaining knowledge about alcohol, tobacco, and other drugs both inside and outside the classroom.The information sources included teachers, parents, and the Internet.However, many students were unaware of the health impact of ecigarettes and addiction as a disease.They stated that they had never learned about these two topics in school.Although e-cigarettes are relatively new, their negative health effects have been reported in Japan and worldwide [27,28].The regulations for conventional cigarettes do not apply to e-cigarettes [29], leading to many advertisements targeting younger generations that present e-cigarettes as a less harmful alternative.We believe that education on this topic is essential in schools.students reported that their sources of information about vaccination were their parents, compared with other topics.It can be speculated that vaccination, especially for minors, is a parental decision, even in the case of the COVID-19 vaccination.There have been reports that many people with vaccine hesitancy obtain information from the Internet and celebrities and tend to be suspicious of healthcare providers [35][36][37][38].Therefore, education and communication are crucial [39,40].Environmental education studies on university freshmen have reported that the most important source of environmental education is the family, which provides long-term information and influences students' knowledge and attitudes [41].Thus, although accurate knowledge must be imparted to children in school, parents should also have access to accurate sources of information.

Overview
This study revealed skewed information sources, with more male students relying on the Internet and friends as information sources and a disparity between sexes in knowledge and self-assessment, especially regarding sexual health.Our results are consistent with a previous study on the source of sexual knowledge, which reported that female students' ideal source of knowledge was school as a primary source, while male students preferred the Internet, friends, and parents in that order [13].However, the disparity in class involvement for knowledge between the sexes on some sexual health topics in our study is notable.
Although more female students reported that they did not learn about "how to use condoms" or "sex and gender" in class, more male students reported that they did not learn about topics related to women's sexual health, such as "women's basal body temperature" or "gestation period and childbirth".We could speculate about several possibilities to explain this disparity.One possibility is actual educational differences based on sex, while the other is perceived differences.Historically, sexual education in Japan was conducted separately based on sex until recently [10,42,43].Due to the long history of sexual education or lack thereof in Japan, students may consider topics not directly connected to their sex as irrelevant to them or not theirs to learn, thinking it is not their concern.With Japan ranking 120 th out of 156 countries in 2021 in the Global Gender Gap Index, it is crucial to educate not only students but also parents and educators that sexual health education is equally essential regardless of sex.Teaching sex education as health education, rather than merely teaching physiological differences and reproductive functions, is crucial to raising awareness of infection prevention, especially sexually transmitted infections, as well as enriching students' lives to build a healthy society [44].However, this survey also demonstrated that practical and essential knowledge of real life was somewhat limited, despite students' knowledge of physiological differences.
This lack of knowledge is likely contributing to the increasing rates of sexually transmitted infections among young people within Japan and worldwide [3,5].With the rise of HIV/AIDS in the 1980s [45,46], the importance of health education, including sex education, came to the forefront.However, political and social background differences have resulted in varying approaches to sexual health education worldwide, with some countries promoting abstinence-only education, lacking sexual health education altogether, or even discouraging its provision.
During the COVID-19 pandemic, educational lectures and practical training were moved to online formats, including healthcare education [47,48].While some countries and regions have accelerated medical students' graduation and assigned them to work [49], the role of medical students during the pandemic remains controversial [50].It is vital for the public, especially healthcare students, to have accurate public health information in this day and age.Thus, understanding these students' knowledge gaps provides an opportunity to supplement and reinforce their understanding of critical health topics.

Limitations
There are some limitations to this study.First, while we surveyed seven college programs, we only conducted the study at one Japanese university.Thus, we cannot ignore the possibility that the results would be different if the study were conducted at a different university or country.Second, to the best of our knowledge, we were unable to find a validated public health knowledge questionnaire suitable for this study, and hence, we selected topics from the curriculum guidelines and current official textbooks ourselves.To provide anonymity, obtain honest answers, and give students the opportunity to gain insight into their own information gaps, we did not test the students; instead, we had them self-report their knowledge or lack thereof.Thus, there is a possibility of inaccurate reporting of their knowledge.Thirdly, we cannot rule out the possibility that students who answer surveys are not representative of the entire population.Finally, this study was conducted during the COVID-19 pandemic.Although the study provides a glimpse into students' knowledge and attitudes in the age of the pandemic, the results may not be generalizable.Therefore, we recommend conducting further research on public health knowledge, both within and beyond Japan, to better understand the current state of health education and identify areas for improvement.

Implications
In Japan, health and sexual health education are not given much emphasis for enrollment in any college, including health-related colleges, as these topics are not included in entrance exams.Therefore, students seldom receive health education, let alone enough to proceed with higher healthcare education.Additionally, Japanese medical students' choice to attend medical school tends to be extrinsically rather than intrinsically motivated, meaning that they choose medicine because their grades are high enough for them to be admitted to medical school.Although there were differences in knowledge on individual topics, there were no significant differences in total knowledge or total self-assessment scores between colleges.Although further research is needed, we can speculate that medical students are not necessarily focusing on learning each topic related to public health due to the reasons above, nor are they as interested in public health topics as can be expected.The health topics in this study are particularly crucial topics derived from preschool curricula and textbooks through the end of high school in Japan and the United States.Hence, they are not expected to be taught in universities or healthcare-related colleges.In other words, the lack of knowledge at this point may not be supplemented before students become healthcare workers.To address this issue, we believe that supplemental education reinforcing public health knowledge at the beginning of university education is beneficial.However, conventional classroom education may not be effective as students may not consider all topics to be of concern.Instead, we propose utilizing student-centered learning, such as problem-based learning [51], projectbased learning [52], and flipped classrooms [53], as additional supplemental basic public health knowledge education after enrollment.We believe that this approach will lay the foundation for future healthcare workers' knowledge and, subsequently, promote the necessary knowledge and awareness indispensable for a healthy society.

Conclusions
In this cross-sectional study, we identified a significant knowledge gap and an overreliance on misinformation sources concerning public health, particularly sexual health, which varied by gender.This finding emphasizes the need for early public health education and awareness-raising efforts in universities, emphasizing the equal importance of health knowledge regardless of gender.Japanese education systems primarily focus on preparing students for university entrance exams, which has led to the neglect of health education as it is not a mandatory part of the exam or university admission requirements.Given the widespread misinformation present in today's world, a policy for improving health education is essential not only to address the lack of accurate knowledge and prevent healthcare workers from acquiring erroneous information but also to raise awareness and decrease the gender gap in sexual health.In conclusion, introducing healthcare-related knowledge to university students, particularly as part of freshmen or healthcare-related schools' curricula, would be beneficial for building a healthy society.This approach would run in parallel with professional training and contribute to creating awareness about public health issues, ultimately leading to a better-informed population and a healthier society.

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Table 1 . Basic characteristics of Participants (n=549). Colleges Characteristics of colleges Total (%) Sex Male (%) Female (%) Undisclosed (%) Medicine
questionnaires.Respondents who did not provide informed consent were excluded from the study.Parental consent was not required since first-year students in Japan are 18 years of age or older.There were no other exclusion criteria.

Table 2 . Summary of (A) students' reported public health knowledge score rate and (B) Self-assessment score.
NOTE:The number of topics about which students reported having knowledge and their self-assessment knowledge level for the topic were calculated to percentage as score.N represents the number of students who answered all questions about self-assessment.(S1 File.Questionnaire Raw Data.Sav) There were 28 questions about whether students had knowledge of the topic and if they had learned it in class.More than 10% of the students were unfamiliar with 12 topics (two for Alcohol, Tobacco, and Other Drugs; nine for Growth, Development, and Sexual Health; and one for Personal and Community Health) of the 28 topics (Table3A).More than 10% of the students responded that they did not learn about 11 topics (two for Alcohol, Tobacco, and Other Drugs; eight for Growth, Development, and Sexual Health; and one for Personal and Community Health) in class (Table

Table 3 . Summary of students' previous knowledge regarding public health topics: (A) Did not know about the topic; (B) Did not learn about the topic in classes.
(A) Did not know about the topic (B) Did not learn about it in classes

) as information source Parent(s) as information source Friend(s) as information source Internet as information source
Values in parenthesis represent percentage of valid N for each category.Results are based on two-sided tests for comparison between sex.The p-value threshold for significance was